Part A

Part A - WHAT IS BEING REPORTED?

Part B

Part B - About the Accident / Incident

Part C

Part C - about the affected person (if there is no injury or ill health - go to Part E)

Part E

Part E - describing what happened

Part F

Part F – Supervisors Investigation

Part G

Part G - about any witnesses

Part H

Part H – recommendations to prevent a similar incident

Part I

Part I - about the person completing this report

The form should be completed and signed by

·  The immediate supervisor of the injured person or the person supervising the work or

·  The person in charge of the area where the accident happened

·  Printed and countersigned by the reporting persons manager

The completed form should be sent to the UK Support Services Director and the Health & Safety Manager within 48 hours of the accident – accidents@tructyre.co.uk. This will happen automatically when you submit this eForm

Serious accidents should be reported immediately by telephone to the Health and Safety Manager or UK Support Services Director.

If appropriate, obtain signed statements from the injured person and from any witnesses giving their accounts of what happened and attach them to this report.  (If you are unsure as to whether statements are needed, please discuss with the Health and Safety Manager - a serious accident or one resulting in more than 7 days absence from the workplace will usually require statements.)  If statements cannot be obtained immediately, if for example the injured person has gone to hospital, do not delay completing this form and informing the Health and Safety Manager about the accident